Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I finished my most recent assignment in Clarinda on May 18. Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading. A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior. Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag. Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty. For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me. I crossed the highway with literally not a single vehicle moving.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center. I’m just back from a working vacation in Petersburg, Alaska.

I went to breakfast with a couple of other docs. All three have worked locums and enjoyed it.

Over coffee we discussed caffeine’s medical effects.

One doc told about a patient with a racing heart (tachycardia) and diabetes. Eventually he stopped the family from bringing in 7 caffeinated sodas a day, and then the patient’s sugars normalized and the heart rate slowed.

The other doctor asked if headache had followed.

I made the observation that I can give anyone a migraine if I give them a high enough dose of coffee for a long enough time and then stop it suddenly. Then had to tell about the worst caffeine addict I ever took care of.

For the sake of this blog and the patient’s identity, I won’t say where or when I met a fellow in his early sixties with insomnia and a racing heart. On the first visit he revealed his 64-cup a day caffeine problem.

“Sixty-four cups a day?” My colleagues asked.

“Yep,” I said. “I had him taper down a dose a day, stay at a dose for two days if he got a headache. It took all summer but I got him down to zero, had him stay at zero for two weeks, then rechallenge. Two days later he was back to 64 cups a day. He just felt lousy without it. Clearly, he wasn’t wired like you and me.”

“What was his blood pressure?” one asked.

“Normal to low,” I answered, my memory making a successful leap over a long chasm of years.

“Did he have Addison’s?”

I came to a screeching halt.

Addison’s disease comes from inadequate cortisone production, a failure of the adrenal glands to produce a hormone necessary to maintain blood pressure and salt retention. The most famous Addisonian patient was JFK, and owed his signature deep tan to the disease. In the course of the last 30 years I have managed a handful of cases (one found by a really sharp psychiatrist) but diagnosed none.

I had to admit I hadn’t considered the diagnosis at the time but I should have.

Then I had to recall lessons learned from managing blood pressure in a suspect pheochromocytoma (docs shorten it to “pheo”) patient.

This disease involves a tumor of the outer adrenal gland, the part that puts out adrenaline. We spent lecture after lecture in med school on the subject. With a case rate of 3 per million, though, primary care doctors can tell when they arrived by the time it takes them to see a case. It took me 30 years.

We talked about alpha and beta blockade, and a drug only used for this vanishingly rare disease.

But we also talked about negotiating, game theory, decision making with imperfect information, the origin of the Syrian nerve gas, Sarin (probably Iraq), Israel’s precarious position, hospital politics, our respective future plans, and problems with Obamacare.

We didn’t always agree, but when we finished we were better doctors for the colloquium.

Synopsis: I’m a family practitioner from Sioux City, Iowa. In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work. In June of 2011 I joined up with the Community Health Center, which provides care for the underserved. I’m now working part-time, which, for a doctor, means 48 hours a week.

I read over the information about the male patient, age 42. The main reason given for the visit came down to concern with alcohol use.

He drinks 6 Jack and Cokes a night, 4 nights out of 7, more on the weekend. Doesn’t smoke. Married. Employed. Wife concerned he’s drinking more than he used to, and he confirms that over the last 4 years his alcohol use has accelerated. He doesn’t have problems at work.

He maintains a normal blood pressure and pulse. His blood work came back as normal with the exception of the liver functions, which, unsurprisingly, run high though not dramatic. I asked for and received an acute hepatitis profile which came back normal, and I couldn’t order an ultrasound.

He has tried to cut down, he gets complaints from his wife about his drinking, those complaints annoy him. But he has never had to have an eye opener, a drink to get going first thing in the morning.

I find no family history of alcoholism; he has no symptoms of depression, no tremor, no headache, and absolutely no sleep disturbance. Sure that he is not an alcoholic, he notes that most of his friends drink more than he does and that most of his socializing has to do with alcohol.

And so the motivational interviewing starts. No judgmental statements, just questions, like What is important to you? How does your drinking fit in with that? Visit after visit, he makes more and more progress whittling away at his tippling and then he starts going months without any alcohol at all. He changes friends, and he gets closer with his patient and loving wife.

The patient didn’t give me permission to write these details because the patient does not exist. The information came to me in a case scenario, a clinical simulation, during my preparation for Family Practice recertification, in the module called Health Behavior.

The case presentation doesn’t match with the reality of my alcoholic patients. As a group, none sleep well, all have family histories of alcoholism, all live in a continuous state of household chaos, going from one crisis to another, sabotaging success and intimacy. A few have normal bowel habits, fewer live without headaches. Most of my alcoholic patients have scintillating, quirky personalities and great senses of humor; yet prone to fits of unreasoning anger, occasional rages, and unrealistic demands on the people around them. Despite tremendous generosity, they betray friends, lovers, spouses and children. Embarrassing others in public leads to progressive isolation. All but the homeless drunks have an enabler, who will sabotage progress towards sobriety. They rarely stay dry without a 12 step program.

Even when sober, they generate chaos, though if they get religion (AA is a religion) they generate less chaos as time goes by.

With all their problems, they’re still fun and exciting to be around. Unlike patient case scenarios.

Synopsis: I’m a family practitioner from Sioux City, Iowa. On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places. Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, right now I’m in Leigh, New Zealand and working in Wellsford, Matakana, and Snell’s Beach.

Today I attended twenty-seven patients.

Four asked me to fill out paperwork so that they would get an income from the government. One denied any medical problem so clearly that I suspected some agency had recruited a patient to try to trap me into bad practice, and I refused. For the others I advised lab investigation, retraining, and lifestyle modification.

Nine patients had superficial skin infections. I heard the term “school sores” applied to a painless blister that rises, then drains pus, and starts to spread. I prescribed a lot of mupuricin (Bactroban). Three patients had fungal skin infections, and I prescribed clotrimazole, available back home over-the-counter as Lotrimin.

The vast majority of the trauma I saw happened to the patients’ left side, and included fracture, sprain, bruise, cut, and contusion.

I learned that cigarettes go for $12 per pack of 30, and that those smokers who protest they can’t afford medical care don’t like me getting out the calculator any more than the smokers at home do.

I calmed three children by playing with my yoyo.

Freezing off warts, a simple operation that requires about fifteen minutes of training, pays obscenely well at home because our system rewards procedures more than cognitive-based actions. Today I had the delight of sending a patient with warts to the practice nurse, who was happy to apply liquid nitrogen.

I sent two patients to the Ear Clinic for wax removal. I’ve written other posts about the satisfaction that comes from getting out a really nasty hunk of cerumen, but I never detailed the occasional frustration and back pain that goes along with it. The frequency of ear wax impaction justifies dedicating a nurse three days a week.

I checked patients’ blood pressures today. For twenty-three years I could say, “Vital signs? That’s the nurse’s job,” but I’m in a different framework here. The nurses have a lot more responsibility and power. They do a good job and free me up for other things, and I don’t mind if I pay the price of collecting all the vital signs I want.

At five, as I settled down to complete my documentation for the day, a nurse asked me if I’d see a patient. The doctor on call had stepped out. Not a problem, I said, and saw an opportunity to demonstrate good team work.

I can’t write any of the specifics of the case because I didn’t get the patient’s permission. But I can say that the nurse did a good workup and that I had the satisfaction of going one layer deeper to uncover a true surgical emergency.

I had seen a couple similar cases a year ago, and even in my own clinic and zone of comfort, my emotions ran high.

In the chest there was a great pain,
On the fingers, a cigarette stain
I thought it was fine
To go testing for Lyme,
The hospitalist thought not the same.

A week before the patient came to see me, crushing sternal chest pain had prompted a visit to Urgent Care. An abnormal electrocardiogram, sky-high blood pressure, sweating, nausea, and shortness of breath resulted in a prescription for an antihypertensive and a recommendation to see a primary care physician within the next week. Which the patient decided meant at least a week.
The patient looked sick, the chest x-ray showed the ravages of tobacco, the blood pressure still ran dangerously high, and the electrocardiogram had gotten worse. The joints of the hand were enlarged in an alarming fashion and the lungs sounded terrible. I called my colleague at the emergency room.

I regard the doc as much a friend as a colleague, and I asked to have the hospitalist call me after the patient has been admitted to investigate a couple of other problems.

The call came hours later. I expressed my concern that the patient had multiple other problems like fatigue, malaise, sexual dysfunction, pain in most joints and morning stiffness. I requested some lab be drawn in the course of the hospitalization.

The hospitalist declined, concerned that the hospital wouldn’t receive reimbursement for the lab work as it didn’t relate to the primary cause for admission. He agreed with checking the thyroid.

Generally I avoid confrontation unlikely to improve things. With great diplomacy, pointing out the enlargement of the hand joints in a pattern suggestive of rheumatoid arthritis, I negotiated a Lyme disease test. I had to point out that tertiary Lyme disease could cause some of the patient’s heart problems.

Research has shown hospitalists get patients discharged alive quicker and for less money than family docs or internists. Those studies played a big factor in my group’s decision to stop hospital work except for OB and newborns.

I was the last amongst us to do regular hospital rounds. By the time I quit, last October, I was superfluous 90% of the time. But the other 10% of the time I did something unique that the consultants, with their narrower and deeper focus, didn’t. My decision came as a tradeoff, an attempt to improve the balancing act.

Tradeoffs rule in the real world. The doctor who sees the patient as a whole human being will probably not get the patient out of the hospital faster or for less expense than the doctor who only takes care of the patient in the hospital.

After my patient’s discharge, I’ll start the workup of the other problems. Most likely I’ll get the patient to feeling better, if not well.
I’m going to go back to hospital work eventually, though I’ve enjoyed the extra hour I get every day that I don’t make rounds. When I restart inpatient care, though, I’ll be in a position to limit my hours.